The topic on dentist’s lips…

on 4 November 2010

There is no doubting the hottest topic of conversation in English dental corridors right now – this month marks the beginning of the registration process with the Care Quality Commission (CQC) for primary care dental services, and also the promised consultation on the proposed charging structure, which is controversial to say the least. At this stage there is no cost attached to registration – that part of the pain only starts next April.

Put simply, every dental practice in England that wishes to provide dental services on or after 1 April 2011 (about 150 days from now) will need to have registered with CQC by then. The crucial point to note is that this applies to private practices just as much as to NHS and mixed practices, to big practices and massive corporate chains as well as the small, single-handed operation located above the fish and chip shop, and to orthodontic practices, denture-only practices and emergency-only practices alike, although there are slightly different considerations according to the basis and extent of the registration (i.e. whether as one or more individuals or as an organisation, whether the regulated services will all be provided from a single location or multiple locations…).

Once registered, each provider of regulated services must, at each location, comply with a series of defined ‘outcome’ measures and be able to demonstrate that one is doing so. All the details are widely available from a variety of sources, and plenty of guidance and hand-holding is also available to help struggling practices through the process (and not least, the jargon). Before the doors to registration were even ajar, I had counted no less than 25 organisations that were offering various packages of information and practical assistance – and at various prices, of course.

There is a widespread view that this additional layer of oversight is an unnecessary and unwelcome duplication of existing regulation and governance – whether by PCTs, the GDC or others. There is also widespread irritation at the fact that primary care medical practices working exclusively in the NHS – who did rather well out of their own ‘new contract’ negotiations before we ended up with the shambolic UDA system that followed – will mostly continue to enjoy an exemption from CQC registration for the time being, although a number of specific ‘higher risk’ procedures have been identified as regulated activities requiring CQC registration even if undertaken wholly within the NHS. Meanwhile, struggling small dental practices will be held firmly under water until the last bubbles are seen to have dispersed. Don’t expect to see any tears of anguish from the Department of Health if and when many of the smallest dental practices fall by the wayside or elect to close their doors. I have observed previously that the controls are out of control – and so they are – but that is too easy, and only part of the story.

A lot of ill-informed nonsense continues to be written about the CQC, perhaps in an attempt to match the ill-informed nonsense that was written to justify what the benefits of the CQC oversight would be. It is plainly ridiculous, for example, to say that CQC registration and regulation directly duplicates GDC registration and regulation – the former is concerned with the healthcare facilities, systems and processes while the latter is concerned with the individuals working within them. There are inevitable areas of overlap because GDC-registered people are operating the systems and processes that CQC will monitor. But the stated aim is to minimise duplication while also ensuring that no gaps are left, through which patient safety and standards of care could slip. Another minor detail is that while associates, assistants, and DCPs are personally registered with and accountable to the GDC in their own right, they are neither registered with, nor accountable to, the CQC. That joy is reserved for those who own and operate the practices, and it is these people who feel overburdened with regulation.

Warm clothingIt was equally ridiculous for the government to have assumed huge financial savings and the freeing-up of precious NHS resources on the basis that CQC registration and oversight would somehow prevent large numbers of vCJD transmissions. What transmissions exactly? The profession is still waiting for much of the evidence to support the requirements of HTM 01-05 and if you plan to wait for the evidence showing the dramatic reduction in dental vCJD transmissions resulting from CQC’s impact upon dentistry, may I suggest that you arm yourself with a blanket, some emergency food rations and a thermos flask – because you could be waiting a very long time.

On the other hand, is it really so unreasonable that the public should be able to expect certain minimum standards whenever they receive dental care and treatment, irrespective of whether it is being provided privately or within the NHS? Of course it isn’t – surely we can agree that it is perverse that a small NHS, vocational training practice gets inspected regularly but a large private practice may never have been inspected at all, by anybody, at any time in its history. Up to now, GDC oversight has been mostly reactive – responding to and acting upon complaints and information after problems have arisen. CQC is designed to be much more proactive – just as the GDC aims to be itself, once its revalidation procedures swing into action in about four years. Some would say that if patients have been happy to attend and pay dentists in private practice, and no complaints have been received, then nothing much will be gained by introducing a heavy layer of governance to demonstrate that all is well.

Quality assurance is about creating environments in which good things are more likely to happen, more often, and where bad things are less likely to happen. There is a fair bit of evidence, though, that quality improvement initiatives work better when those whose activities are the intended subject of the improvement, are involved and actively engaging with the process rather than feeling themselves being dragged into it or having it imposed upon them – and they work best of all when hearts and minds are first won over by persuading them why the new and additional processes are necessary.

VirtualityInstead, the picture is depressingly familiar, with the decision being made first, and only then the search for some ‘virtual’ evidence to support it, in order to remedy a ‘virtual’ problem, or one that has been extrapolated from medical and/or hospital experience. In many cases the shape of the CQC requirements and standards are based upon speculation and assumptions, even if they do make sense in abstract terms. Ironically, one of the recurring CQC expectations is that of compliance with the evidence base and published guidance. The result is that instead of bringing the body of the profession along with the change, the chorus is one of opposition and resentment – and all the positive aspects of CQC (and there are many) get lost in the growing resistance movement. It is also true that very many practices are doing most of what is required already. Their journey will therefore be short (although not without cost) while those who start furthest from the intended standard face the hardest journey and the greatest cost as the quest for the proverbial ‘level playing field’ leaves base camp.

One of the less obvious, but very clever sub-plots in all of this is the continuing erosion of self-regulation and progressive disempowerment of dentists. While still technically independent contractors, it doesn’t feel much like independence anymore. It feels increasingly like employment without any of the fringe benefits. CQC has also made clear its intention to use non-dentists to sift through the ‘evidence’, visit practices and check compliance. With the proposed demise of the PCTs, their dental advisers will also disappear.

The colleague-to-colleague oversight of the Dental Reference Service in England and Wales has been progressively dismantled over several years, and over 30 of them were shown the way to the departure lounge only last month – their services no longer being required. We have already lost the last vestige of self-regulation at the GDC, and through the most elegant sleight of hand, the dental profession will soon be left meeting the entire cost of its own regulation both by the GDC and by CQC. In the old days, the State was paying for the whole DPB empire (and it even employed the dental officers directly until the late 1980s), the PCT commissioning industry, and shedloads of other ‘arms length bodies’.

I think we are gradually getting the message. Or if not, we should be.